This is an application for an HSR&D Career Development Award (CDA) for Dr. Kali Thomas, a Research Health Scientist in the Center of Innovation for Long-Term Services and Supports (LTSS) at the Providence VA Medical Center. Dr. Thomas' long-term career goal is to conduct rigorous research that will inform policies and practices aimed at advancing the VA's home and community-based service delivery, thereby improving the quality of life and health outcomes of Veterans needing LTSS. The demand for LTSS within VA is expected to continue to grow dramatically as the Veteran population ages. This CDA will focus on understanding the role of participant-directed (PD) cash benefit programs provided by VA to meet the growing need for LTSS. The VA, through its Veterans Health Administration (VHA) and Veterans Benefits Administration (VBA), offers separate and distinct PD cash benefit programs for LTSS. The VHA's Veteran-Directed Home and Community Based Services program (VD-HCBS) provides Veterans with a monthly budget based on the extent of their disability giving them the opportunity to purchase goods and services that best meet their needs. The VBA offers two enhanced monthly benefits to disabled and homebound Veterans receiving pension or compensation: the Aid and Attendance (A&A) and Housebound benefits. In non-VA populations, similar programs have been cost- effective and improved participants' outcomes. However, in VA, information about effectiveness and access to these programs is limited: there remains little to no understanding of who receives these PD cash benefits, how Veterans are utilizing these benefits, their satisfaction with the benefits, their consumption of medical and institutional care, nor the outcomes associated with receiving these cash benefits. Therefore, the objective of this application is to establish a foundation of research about the VA's PD cash benefit programs in order to develop interventions aimed at improving access to these benefits, promote a national understanding of Veterans' experiences with these benefits, and set the stage for a research career evaluating and improving the delivery of LTSS to Veterans. This CDA will provide Dr. Thomas with the support necessary to accomplish the following goals: (1) to become an expert in conducting rigorous, practical program evaluation and implementation research; (2) to achieve proficiency in comparative effectiveness research, primary data collection, and qualitative research methodologies (3) to become familiar with delivery of LTSS at VAMCs and (4) to reach research independence. These goals will be achieved through the training and applied, mixed methods formative research she has proposed in this award. Specifically, her research seeks to (1) use administrative data to determine which eligible Veterans being served by which Medical Centers enroll in VA's PD cash benefit programs, (2) explore reasons for variation in enrollment in VD-HCBS, A&A and Housebound benefits across VAMCs with interviews of VAMC personnel (3) conduct interviews with Veterans to describe their experiences with the VA's PD cash benefit programs and (4) establish the effectiveness of the VA's PD cash benefit programs in controlling healthcare costs by using sophisticated methodologies to compare Veterans' healthcare utilization to that of Veterans receiving traditional LTSS. This research is significant because it will provide a critical understanding of who receives VA cash benefits for PD care, causes for variation, Veterans' perceptions of PD programs, and knowledge of their outcomes. The experience and skills gained through the integrated training and research plan will accelerate progress toward Dr. Thomas' long- term research goal and will set the stage for implementing innovative solutions to increase the access to cash benefits and obtaining a national picture of Veterans' experiences with these benefits, to be proposed in future Merit award applications. Dr. Thomas' current and future research will evaluate programs and implement innovative solutions to integrate VHA and VBA, creating a ?One VA? system to enable older, vulnerable Veterans to receive appropriate, Veteran-centered, and cost-effective LTSS in the setting of their choice.